Reducing Hospital Readmissions for CHF Patients through Pre-Discharge Simulation- Based Learning
|
|
- Sheryl Hensley
- 6 years ago
- Views:
Transcription
1 Reducing Hospital Readmissions for CHF Patients through Pre-Discharge Simulation- Based Learning Lee Greer, MD, MBA, Amy T. Fagan, RN, MPH, PhD, and Eric A. Coleman, MD, MPH ABSTRACT Objective: To describe the self-care college, an innovative initiative designed to reduce hospital readmissions for congestive heart failure (CHF) patients. Methods: CHF patients at North Mississippi Medical Center are asked to participate in a self-care college prior to discharge. Participants rotate through 3 learning stations: weight, diet and medications. At each station, they are asked to perform the tasks they will be required to do at home. By engaging patients in the learning process, they are activated to assume responsibility for their care. This approach has the added advantage of providing a feedback loop, allowing the health care team to road test the proposed care plan to determine the likelihood that the patient (and family caregivers) will be able to execute following discharge. Results: Since the self-care college was implemented in 2011, the 30-day readmission rate for CHF patients at NMMC has been reduced from 16.8% to 12.85%. There has also been a reduction in the observed to expected CHF readmissions ratio, from 0.90 to Conclusion: Although the self-care college targets CHF patients, it is likely that this type of initiative could be applied for rural patients with other chronic illnesses, such as asthma, COPD, and diabetes. It is a relatively simple and inexpensive program (approximately $30,000 per year, primarily in personnel expenses, or roughly the cost of 3 hospital readmissions) that does not require sophisticated technology or equipment, and could easily be replicated in health care settings across the country. Congestive heart failure (CHF) is a chronic and costly condition that affects approximately 5.1 million people in the United States, with an additional 670,000 diagnosed yearly [1]. Heart failure is the most common cause of hospitalization among adults over 65. Nearly 25% of patients hospitalized with heart failure are readmitted within 30 days [2]. Medical management of people living with CHF and other chronic illnesses presents a challenge for health care providers. Due to their often complex medical conditions and limited opportunities to learn self-management skills, patients in rural areas with CHF are at increased risk for complications and hospital readmission [3]. Many approaches have been considered to reduce heart failure readmissions, including efforts to improve self-management skills. Initiatives that engage patients in the process of learning to self manage their illness may activate them to assume responsibility for their care. North Mississippi Health Services (NMHS) is an integrated regional health care organization with over 5000 employees that serves more than 700,000 residents of 24 primarily rural counties in north Mississippi and northwest Alabama. The flagship of the NMHS system is North Mississippi Medical Center (NMMC), a 650- bed regional referral center in Tupelo. NMHS is one of the largest rural health systems in the United States, and the statistics for its service area reflect these challenges: the prevalence and age-adjusted mortality rates for most chronic illnesses exceed those for the nation as well as for Mississippi, which itself historically ranks at or near the bottom of almost all health status indicators [4 6]. On average, 800 patients with CHF are discharged annually from NMHS s hospitals, and more than 2900 patients diagnosed with CHF are active NMMC clinic patients. NHMS is addressing these challenges through a series of innovative quality improvement initiatives. NMHS s From North Mississippi Health Services, Tupelo, MS (Drs. Greer and Fagan), and the University of Colorado, Denver, CO (Dr. Coleman). Vol. 21, No. 11 November 2014 JCOM 513
2 Simulation-based learning newest initiative is the CHF self-care college. In this paper, we describe the initiative, its implementation, and evaluation to date. SELF-CARE COLLEGE Background The idea for the self-care college grew out of discussions with Nurse Link coaches, registered nurses employed by NMHS, who call CHF patients at their homes following discharge. The first call, within 48 hours following discharge, is to reconcile medications, conduct patient education, and confirm follow-up appointments. Three subsequent weekly calls focus on additional education and recognizing red flags utilizing the IHI teach back method, in which patients are asked to restate instructions or concepts in their own words. During regular biweekly meetings with physicians to monitor patient progress, Nurse Link coaches observed that many patients (and in some cases, their caregivers) had difficulty following their discharge instructions. In particular, patients did not understand how to properly weigh themselves, how and when to take their medications, or how to ensure their diet met physicians guidelines. Although patients were being provided with written and oral instructions as part of the discharge process and through post-discharge follow-up communications, they did not properly implement those instructions once they returned home. A multidisciplinary team consisting of NMHS physician leaders and representatives from pharmacy, dietary, physical therapy, cardiac rehabilitation, nursing, and case management met to brainstorm ways to overcome this challenge. What emerged from these discussions was the idea for a simulation-based learning experience for patients prior to discharge. Simulation-based learning is not a new concept. It has been utilized for many years in aviation, health care, and the military as a way to train people in highrisk professions, using realistic scenarios in a controlled environment, without risk to participants. Participants receive immediate feedback from trained instructors as to whether they are performing critical functions properly, providing an opportunity to practice areas in which there is a need to improve technique, speed, or implementation of actions in the correct order. It has been proven to be a highly effective type of learning experience that results in better retention of skills, both cognitive and procedural, and it reduces preventable adverse events [7]. Simulationbased learning in medicine has traditionally been limited to clinician education, where providers practice on computerized patient simulators or other substitutes for live patients. To our knowledge, the concept of simulation learning has not been extended to patient education initiatives. Simulation-based learning would actively engage patients in learning the necessary self-care skills rather than being passive recipients of information. As the self-care college team often says, You don t learn to ride a bike by reading a book; neither should you be asked how to manage CHF by reading a pamphlet. Learning Stations Participants in the self-care college rotate sequentially through 3 learning stations: weight, diet and medications. The main location for the self-care college is a conference room on the cardiac unit of NMMC. At each station, patients are asked to perform the tasks they will be required to do at home. If they cannot complete the task, the deficit is recognized and addressed. This might include referring the patient to home health care, ensuring that a Nurse Link coach contacts him or his caregiver to reiterate medication instructions or ensuring that his case manager refers him to appropriate social services. Although no formal cognitive assessment is conducted, if the team perceives that the patient has a cognitive impairment that could prevent him from being able to perform self-care activities, this information is relayed to the case manager. At the weight station, a physical therapist or cardiac rehabilitation professional stresses the importance of weighing daily and has the patient demonstrate weighing himself, providing feedback if necessary, to ensure that each patient knows how to properly weigh himself. If the patient does not own a scale, or needs an adaptive scale (such as one with extra large numbers or one that talks ) and is financially unable to purchase one, he is given one to take home. At the diet station, a registered dietitian asks the patient what he eats on a typical day, and he is given helpful dietary choices based on his responses. A display at this station provides sample food labels from some common foods, so that patients can see where and how to locate important nutrition information, such as sodium content. The dietitian also discusses fluid restriction and provides the patient and/or caregiver with a written copy of dietary recommendations. In the words of one selfcare college patient, I had to push that salt shaker away, but I also learned that salt comes in cans and boxes. I 514 JCOM November 2014 Vol. 21, No. 11
3 learned to read food labels for sodium content and to stay away from processed foods. At the medication station, a pharmacist reviews the patient s heart failure medications, has the patient simulate how he will obtain, organize, and remember to take his medications at home, offers feedback and instruction, and answers questions. The pharmacist also provides the patient with a 7-day medication planner for home use and has the patient demonstrate completing the planner. After the patient has been through the 3 learning stations, a Nurse Link coach enrolls him in the 4-week callback program. In addition, home health care representatives are available to discuss the benefits of home health to help manage their CHF at home. Finally, each patient receives a CHF self-care college folder, with educational materials including a weight log/calendar; information on smoking cessation, medications, and prescription assistance; a personal health record; control zones for CHF management; red flags and warning signs/symptoms to report; and when to call the doctor. When the patient has completed the self-care college, the self-care college team huddles to ensure that the patient is adequately prepared to transfer to their next health care destination. If not, recommendations are made to their provider to ensure a smooth transition. Family members and/or caregivers are encouraged to participate in the self-care college experience whenever possible and are included in the huddle. Implementation Prior to implementing the self-care college, the team identified 4 major challenges and developed strategies to address them. In many cases, strategies were effective in addressing more than one challenge. Coordinating the allocation of resources among different departments: as with any new initiative, finding time in everyone s schedule to accommodate additional tasks is a challenge. In order to ensure that the self-care college was streamlined into everyone s schedule, the team determined a set time of day that it would take place. Gaining buy-in from referring physicians: because referrals from physicians would be critical to the success of the self-care college, the team spent significant time meeting face-to-face with physicians to explain the reason for the program and how it would be implemented. In almost every case, physicians enthusiastically agreed to refer appropriate patients to the self-care college. Although NMHS operates in a fee-for-service environment (and physicians therefore are not financially incentivized to reduce readmissions), it has a strong culture of compassion and caring, focused on innovation, vision, and performance results. Physician buy-in was also facilitated by rolling out the program one floor at a time, so that the team and the physicians could become comfortable with the process. The nurses and case managers on each unit were educated about the program and could prompt the physician to consider placing a referral to the program if warranted. Logistical issues in getting the patients to the self-care college room: many CHF patients have significant mobility challenges, and the team discovered that it was not always possible for the patient to be transported to the room where the self-care college was set up, particularly as the program expanded into different wings of the medical center. As a result of feedback from patients and staff regarding the logistical issues around transporting patients to the college, the team developed a mobile version that is brought directly to the patient s room. A cart holds scales, patient folders, medication planners, and all the tools necessary to present the program. Each member of the team rotates into the room to present their piece of the program. In addition to ensuring that patient mobility issues were not an obstacle to participation, developing the mobile program made the most efficient use of the team s time in serving these patients, and no patient has been turned away due to having reached capacity at the stationary self-care collage. Completing the self-care college in a timely fashion: In order to make most efficient use of time (for both the team and the patient), the content for each station was designed to last no more than 15 minutes on average. We have also worked with physicians to encourage referrals prior to the day of discharge, so that patients can be scheduled efficiently. PROGRAM EVALUATION Because the self-care college is one of several initiatives being implemented by NMHS with a focus on reducing readmissions for CHF patients, it is difficult to identify the specific effect of the self-care college on readmissions. However, since implementation in 2011, we have seen a relative rate reduction in CHF readmissions of approximately 23%, and a reduction in the observed to expected CHF readmissions ratio from 0.90 to Vol. 21, No. 11 November 2014 JCOM 515
4 Simulation-based learning In addition, referrals have steadily increased since the program began, which suggests that physicians are confident in the program and its ability to improve outcomes. Beyond the quantifiable measures available to us, comments from patients indicate that the self-care college is improving the quality of life for many of our patients. Two patients noted the following: I felt like I wasn t just thrown out there by myself... I was scared because I didn t know anything about this disease. The program let me know I wasn t alone. I eat much differently. I am learning to eat less and eat the right foods...i check my blood sugar every day now, and I weigh myself every day. I know if I weigh more than 244 pounds, I need to call someone. While patient and physician feedback has been very positive as far as the effectiveness in teaching patients important self-care skills, we discovered another benefit: not only does the self-care college give patients hands-on practice with skills they will need and the opportunity to ask questions, the team has an opportunity to observe patients actually performing self-care activities, ask the patient questions about how they will follow their discharge instructions, and evaluate whether they are ready to be discharged. Given the distances that many of these patients travel to receive care in the hospital, having insight into their capability prior to discharge is an important advantage. For example, a patient completing the weight module was having difficulty reading the numbers on the scales due to poor visual acuity, which had not been otherwise noted in his hospital records. The team was able to fit him for a scale with large numbers. In other cases, we have found patients who are unable to identify lowsodium foods. To help them meet dietary guidelines, the dietitian uses a food prop to show them how to read and understand the Nutrition Facts label and then discusses alternative food choices with them. At the medication station, patients bring in all the medications they are currently taking and are asked to identify when, how, and why they take each medication. Frequently, we find that patients do not understand the instructions on the label or that they have duplicate medications because one is a generic and another is a brand name. We can provide the patient with a medication planner that helps ensure their medications are taken properly. LESSONS LEARNED As with any new initiative, the self-care college team learned important lessons throughout the implementation process. Chief among these was that flexibility is critical to success. We listened to feedback from patients, physicians, and hospital staff and modified the program to ensure that it was integrated as seamlessly as possible into everyone s schedule. Feedback was obtained through a variety of methods, including medical staff meetings, discussions with patients and their family members, and feedback from Nurse Link coaches. Feedback led to a number of changes, including development of the mobile self-care college and changing the timing from the day of discharge to the day prior to avoid conflicts with other day-of-discharge activities. An additional lesson learned, which was actually a process of learning, was how important it is for self-care college team members to be active listeners. As opposed to the didactic approach, where clinicians provide instructions to patients, the self-care college team learned to ask questions of the patients and to actively listen to the responses, filling in the gaps where necessary. Interestingly, we found that this was also a learning process for the patients, many of whom are unaccustomed to engaging in dialogue with their doctors and to being active participants in their health care. They were not all initially comfortable with the concept of simulation, but our staff learned different ways to introduce patients to it, so that ultimately most seemed to enjoy the program. TAKE-AWAY POINTS For health care organizations considering implementing a self-care college or similar initiative, we offer a few key points: 1. Consider the benefits beyond reducing readmissions: at NMHS, we have found that the self-care college has positively impacted patient satisfaction. For the past 2 years, our HCAHPS scores have consistently been well above the top performance threshold, a top quartile performer in Premier s quality database (Premier, Inc., a health care performance improvement alliance of approximately 3000 U.S. hospitals). While it is difficult to correlate patient satisfaction scores with any one initiative, we hear from patients, physicians, and nursing staff that the self-care college greatly increases effective communication between provider and 516 JCOM November 2014 Vol. 21, No. 11
5 patient. We have also found that some of our biggest advocates are now the cardiologists who refer patients. 2. Analyze your operational readiness: this is a low-tech but high-touch program. While it requires a minimal financial investment DISCUSS, it does require strong organizational leadership and staff buy-in to make it successful. Nursing staff are likely to buy into the program because they will not have to deliver discharge education to patients in addition to the many other responsibilities they have. Administrators should see that patient satisfaction will improve and readmissions will decrease. Ultimately, it is up to the program champion to make it clear to key stakeholders what the advantages are, and to include them in the process of developing the self-care college. 3. This is the future of medicine: The self-care college is just one example of a team-based approach to medicine. Most of the disciplines on our team did not know each other prior to the program. We now have established a line of communication that permeates throughout the hospital to the outpatient setting. Based on our success with the CHF self-care college, the next logical step will be to create self-care colleges for other common disease states, such as asthma/copd or diabetes. However, while the value of this model for patient education has clearly been demonstrated, the team has also contemplated its application for staff training. Many large hospitals already use patient simulation manikins in nursing education, but the cost of this high-tech equipment is out of reach for many smaller, community hospitals. The possibility to create low-cost, low-tech simulation training experiences for clinicians similar to that provided by self-care college for patients bears examination. Corresponding author: Lee Greer, MD, MBA, 830 S. Gloster St., Tupelo, MS 38801, lgreer@nmhs.net. Financial disclosures: None. REFERENCES 1. Yancy CW, Jessup M, Bozkurt B, et al; American College of Cardiology Foundation; American Heart Association Task Force on Practice Guidelines ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2013;62:e Hospital compare (Internet). Baltimore: Centers for Medicare and Medicaid Services; Available at gov/hospitalcompare. 3. Health disparities a rural-urban chartbook. Columbia, SC: South Carolina Rural Health Research Center; America s health rankings [Internet]. Minnetonka: United Health Foundation; Available at 5. County health profiles 2007 [Internet]. Jackson: Mississippi State Department of Health; Available at msdh. ms.gov/msdhsite/_static/31,0,299,463.html. 6. County Health rankings and roadmaps [Internet]. Madison: University of Wisconsin Population Health Institute; Available at 7. Aebersold M, Tschannen D. Simulation in nursing practice: the impact on patient care. OJIN: Online J Iss Nurs 2013; 18(2):Manuscript 6. Copyright 2014 by Turner White Communications Inc., Wayne, PA. All rights reserved. Vol. 21, No. 11 November 2014 JCOM 517
Thinking Differently about Hospital Readmissions
Thinking Differently about Hospital Readmissions LaNita Knoke RN, BS, CMCN Healthcare Strategist Senior Care Continuum Each Home Instead Senior Care franchise office is independently owned and operated.
More information2015 Congestive Heart Failure. Program Evaluation. Our mission is to improve the health and quality of life of our members
2015 Congestive Heart Failure Program Evaluation Our mission is to improve the health and quality of life of our members 2015 Congestive Heart Failure Program Evaluation Program Title: Congestive Heart
More information2017 Congestive Heart Failure. Program Evaluation. Our mission is to improve the health and quality of life of our members
2017 Congestive Heart Failure Program Evaluation Our mission is to improve the health and quality of life of our members 2017 Congestive Heart Failure Program Evaluation Program Title: Congestive Heart
More informationPresenter Disclosure Information
The following program is co-provided by the American Heart Association and Health Care Excel, the Medicare Quality Improvement Organization for Kentucky. 3/1/2013 2010, American Heart Association 1 1 2
More informationMedical Management. G.2 At a Glance. G.3 Procedures Requiring Prior Authorization. G.5 How to Contact or Notify Medical Management
G.2 At a Glance G.3 Procedures Requiring Prior Authorization G.5 How to Contact or Notify Medical Management G.6 When to Notify Medical Management G.11 Case Management Services G.14 Special Needs Services
More informationTRANSITIONS OF CARE: INCREASING PATIENT ENGAGEMENT AND COMMUNICATION ACROSS HEALTH CARE SETTINGS
TRANSITIONS OF CARE: INCREASING PATIENT ENGAGEMENT AND COMMUNICATION ACROSS HEALTH CARE SETTINGS Leslie Lentz, BA Care Transitions Project Coordinator Health Care Excel, the Indiana Medicare Quality Improvement
More informationMedical Management. G.2 At a Glance. G.2 Procedures Requiring Prior Authorization. G.3 How to Contact or Notify Medical Management
G.2 At a Glance G.2 Procedures Requiring Prior Authorization G.3 How to Contact or Notify G.4 When to Notify G.7 Case Management Services G.10 Special Needs Services G.12 Health Management Programs G.14
More informationPRISM Collaborative: Transforming the Future of Pharmacy PeRformance Improvement for Safe Medication Management
PRISM Collaborative: Transforming the Future of Pharmacy PeRformance Improvement for Safe Medication Management Mission: To improve the health of the people of Connecticut through safe and effective medication
More informationThe Care Transitions Intervention
The Care Transitions Intervention Kimberly Irby, MPH Colorado Foundation for Medical Care www.cfmc.org/integratingcare Acknowledgments: Objectives To provide an overview of the Care Transitions Intervention
More informationCare Transitions The most interesting things happen in doorways --Inferno, Dan Brown. The Triple Aim through the Lens of Care Transitions
Care Transitions The most interesting things happen in doorways --Inferno, Dan Brown An Under recognized Key to Improving Transitional Care: Feedback Loops Eric A. Coleman, MD, MPH But Dr. Coleman, we
More informationProviding and Billing Medicare for Transitional Care Management
PYALeadership Briefing Providing and Billing Medicare for Transitional Care Management Updated November 2014 2014 Pershing Yoakley & Associates, PC (PYA). No portion of this white paper may be used or
More informationPartner with Health Services Advisory Group
Partner with Health Services Advisory Group Bonnie Hollopeter, LPN, CPHQ, CPEHR Health Services Advisory Group (HSAG) Quality Improvement Lead Rosalie McGinnis, MS, RN HSAG Quality Improvement Lead November
More informationUse Case Study: Remote Patient Monitoring for Chronic Disease
Use Case Study: Remote Patient Monitoring for Chronic Disease Hackensack Alliance Accountable Care Organization New Jersey March 2014 The Hackensack Alliance Accountable Care Organization (ACO) was established
More informationThe TeleHealth Model THE TELEHEALTH SOLUTION
The Model 1 CareCycle Solutions The Solution Calendar Year 2011 Data Company Overview CareCycle Solutions (CCS) specializes in managing the needs of chronically ill patients through the use of Interventional
More informationCollaborative Activation of Resources and Empowerment Services Building Programs to Fit Patients vs. Bending Patients to Fit Programs
Organization: Solution Title: Calvert Memorial Hospital Calvert CARES: Collaborative Activation of Resources and Empowerment Services Building Programs to Fit Patients vs. Bending Patients to Fit Programs
More informationImproving Patient Safety Across Michigan and Illinois
Improving Patient Safety Across Michigan and Illinois Designing Your Readmission Reduction Approach February 17, 2016 Agenda Peer to Peer Learning Network/Improvement Poster (Illinois) Designing your Readmissions
More informationUsing Facets of Midas+ Hospital Case Management to Support Transitions of Care. Barbara Craig, Midas+ SaaS Advisor
Using Facets of Midas+ Hospital Case Management to Support Transitions of Care Barbara Craig, Midas+ SaaS Advisor What does Transitional Care Include? Transitional Care is the smooth conversion of a patient
More informationPursuing the Triple Aim: CareOregon
Pursuing the Triple Aim: CareOregon The Triple Aim: An Introduction The Institute for Healthcare Improvement (IHI) launched the Triple Aim initiative in September 2007 to develop new models of care that
More informationPartnering with Pharmacists to Enhance Medication Management
Partnering with Pharmacists to Enhance Medication Management Tamara Ravn PharmD BCACP Staff Pharmacist Clinical Cancer Pharmacy Froedtert & The Medical College of Wisconsin April 6, 2016 Objectives Describe
More information6/3/ National Wellness Conference. Developing Strategic Partnerships to improve the Health and Wellness of the Community. Session Objectives
2015 National Wellness Conference Developing Strategic Partnerships to improve the Health and Wellness of the Community. Kimberly Sbardella, R.N. Manager, Community Health & Wellness Carolinas HealthCare
More informationPresenter Disclosure Information
The following program is co-provided by the American Heart Association and Health Care Excel, the Medicare Quality Improvement Organization for Kentucky. 2/27/2013 2010, American Heart Association 2 1
More informationImproving Care Transitions
Care Transitions Collaborative Improving Care Transitions Laura Cole, RN South Carolina Partnership for Health SPECIFIC QUESTIONS WE WILL EXPLORE TODAY: Why the focus on care transitions? What strategies
More informationWisconsin Homecare Organization
Wisconsin Homecare Organization Competitive Strategies: Key Elements for Thriving in a High-Stakes Outcomes Market Lynda Laff Strategic Healthcare Programs, LLC Thursday, May 15, 2008 2:00 p.m. 3:30 p.m.
More informationEffective Care Transitions to Reduce Hospital Readmissions
Effective Care Transitions to Reduce Hospital Readmissions November 8, 2017 Anchorage, Alaska The vicious cycle of readmissions What is Care Transitions? The movement of patients across settings, referred
More informationCoordinated Outreach Achieving Community Health (COACH) for Heart Failure Learning Objectives
Coordinated Outreach Achieving Community Health (COACH) for Heart Failure Session C917 October 9, 2015 Colleen Cameron, DNP, FNP-BC Rochelle Eggleton, MBA, BS, RN Susan Spink, BSN, RN-BC Linda Griffin,
More informationExpanding Your Pharmacist Team
CALIFORNIA QUALITY COLLABORATIVE CHANGE PACKAGE Expanding Your Pharmacist Team Improving Medication Adherence and Beyond August 2017 TABLE OF CONTENTS Introduction and Purpose 1 The CQC Approach to Addressing
More informationCOMMUNITY HEALTH NEEDS ASSESSMENT HINDS, RANKIN, MADISON COUNTIES STATE OF MISSISSIPPI
COMMUNITY HEALTH NEEDS ASSESSMENT HINDS, RANKIN, MADISON COUNTIES STATE OF MISSISSIPPI Sample CHNA. This document is intended to be used as a reference only. Some information and data has been altered
More informationCHF Education March Courtney Reaves, BSN, RN-BC Amy Taylor, BSN, RN Corey Paris, BSN, RN, CCRN
CHF Education March 2015 Courtney Reaves, BSN, RN-BC Amy Taylor, BSN, RN Corey Paris, BSN, RN, CCRN Objectives To improve patient outcomes Decrease CHF readmissions Improve patient and family compliance
More informationYour Guide to Home Hemodialysis Module 1: Introduction
Your Guide to Home Hemodialysis Module 1: 6.0959 in Your Guide to Home Hemodialysis Module 1: This manual was created by the Ontario Renal Network in collaboration with dialysis training programs in Ontario
More informationSpecial Needs Plans (SNP) Model of Care (MOC) Initial and Annual Training
Special Needs Plans (SNP) Model of Care (MOC) Initial and Annual Training 2018 Learning Objectives Program participants will be able to: List the three overall goals of the SNP Model of Care Describe the
More informationMinicourse Objectives
Session M1 This presenter has nothing to disclose SINAI-GRACE HOSPITAL Vanguard Health Systems/Detroit Medical Center Peggy Segura RN, MSN, FNP-BC Nurse Practitioner, Quality & Safety/Clinical Effectiveness
More informationPatient Activation Using Technology- Supported Navigators
Patient Activation Using Technology- Supported Navigators March 2, 2016 1PM Sands Expo: Lando 4205 Merrily Evdokimoff, RN, PhD Kinergy Health LLC Conflict of Interest Merrily Evdokimoff, RN. PhD Consulting
More informationWebEx Quick Reference
IHI Expedition: Effective Implementation of Heart Failure Core Processes Peg Bradke, RN, MA, Faculty Christine McMullan, MPA, Director December 15, 2011 These presenters have nothing to disclose WebEx
More informationtotal health and wellness
total health and wellness Programs exclusively for our Blue Shield members total health and wellness Whether you want to ease stress, lose weight, or quit smoking we ll help you reach your goals. Our health
More informationSolution Title: Population Health: A Paradigm Shift in how we care for Behavioral Health Patients
Solution Title: Population Health: A Paradigm Shift in how we care for Behavioral Health Patients Overview of Project A drive to Population Health and changes in reimbursement have prompted the need to
More informationCMS Proposed Rule. The IMPACT Act. 3 Overhaul Discharge Planning Processes to Comply With New CoPs. Arlene Maxim VP of Program Development, QIRT
Overhaul Discharge Planning Processes to Comply With New CoPs Arlene Maxim VP of Program Development, QIRT 1 CMS Proposed Rule Included discharge planning specifics However, when the CoPs were finalized,
More informationACHIEVING POPULATION HEALTH: THE POWER OF TEAM BASED CARE
ACHIEVING POPULATION HEALTH: THE POWER OF TEAM BASED CARE JAMES JERZAK M.D. KATHY KERSCHER, MBA BELLIN HEALTH GREEN BAY WI IHI NATIONAL FORUM 12 13 2017 2 GREEN BAY, WISCONSIN Agenda Why Team-Based Care
More informationRenee Coughlin PT, DPT, MHS Steven Pamer PT, MPA, CGS
Improving Chronic Care Renee Coughlin PT, DPT, MHS Steven Pamer PT, MPA, CGS The Financial Imperative United States Economy - Cost $1 trillion annually and could reach $6 trillion by 2050 Failure to contain
More informationSENTARA HEALTHCARE. Norfolk, VA
SENTARA HEALTHCARE Norfolk, VA 1 Sentara Healthcare Overview 11 Acute Care Hospitals in Virginia with a total of 2572 licensed beds 1E Extended dstay hospital 9 Ambulatory Care Campuses; 5 with freestanding
More informationSmall changes. Big. Savings.
Small changes. Big Savings. CASE STUDY Company: Froedtert Health Wellness Program: Wellness Works No. of Employees: 9,000 Participation Rate: About 80% ROI: $3.2 million since 2009 Wellsource Products
More informationIHI Open School Advanced Case Study
IHI Open School Advanced Case Study Andrea Jewell & Ellen Odai Team: Crazy about IPC The Ottawa Hospital; University of Ottawa IHI Open School Chapter October 14, 2010 Overall process map What contributed
More informationUPDATE ON MEANINGFUL USE. HITECH Stimulus Act of 2009: CSC Point of View
HITECH Stimulus Act of 2009: CSC Point of View UPDATE ON MEANINGFUL USE Introduction The HITECH provisions of the American Recovery and Reinvestment Act of 2009 provide a commanding $36 billion dollars
More informationHow to Initiate and Sustain Operational Excellence in Healthcare Delivery: Evidence from Multiple Field Experiments
How to Initiate and Sustain Operational Excellence in Healthcare Delivery: Evidence from Multiple Field Experiments Aravind Chandrasekaran PhD Peter Ward PhD Fisher College of Business Ohio State University
More informationImplementation Guide Version 4.0 Tools
Implementation Guide Version 4.0 Tools Program Overview Purpose of the Guide This Guide is intended primarily for INTERACT champions and trained educators who are responsible for implementing and sustaining
More informationReducing Readmission Case Stories Discussion of Successes
Reducing Readmission Case Stories Discussion of Successes University of California, San Francisco Maureen Carroll RN, CHFN Transitional Care Manager Heart Failure Program Coordinator UnityPoint Cedar Rapids
More informationImproving Transitions of Care
Improving Transitions of Care A Strategy to Defer Decline How the Foundation Got Started with Care Transitions First Quality Improvement Collaborative 2005-2006 Teams chose palliative care or transitions
More informationCMS-0044-P; Proposed Rule: Medicare and Medicaid Programs; Electronic Health Record Incentive Program Stage 2
May 7, 2012 Submitted Electronically Ms. Marilyn Tavenner Acting Administrator Centers for Medicare and Medicaid Services Department of Health and Human Services Room 445-G, Hubert H. Humphrey Building
More informationLow-Cost, Low-Administrative Burden Ways to Better Integrate Care for Medicare-Medicaid Enrollees
TECHNICAL ASSISTANCE BRIEF J UNE 2 0 1 2 Low-Cost, Low-Administrative Burden Ways to Better Integrate Care for Medicare-Medicaid Enrollees I ndividuals eligible for both Medicare and Medicaid (Medicare-Medicaid
More informationThe Community Care Navigator Program At Lawrence Memorial Hospital
The Community Care Navigator Program At Lawrence Memorial Hospital Presented By: Linda Gall, MSN, RN, ACM Director of Care Coordination October 21, 2011 Learning Objectives: 1. Describe the vision and
More informationCASE MANAGEMENT TOOLS:
CASE MANAGEMENT TOOLS: ENGAGING PATIENTS AS PARTNERS IN CARE September 19, 2017 Chinle Service Unit Diabetes Program Navajo Area Indian Health Service Miranda Williams Krista Haven CHINLE SERVICE UNIT
More informationSNF REHOSPITALIZATIONS
SNF REHOSPITALIZATIONS David Gifford MD MPH SVP Quality & Regulatory Affairs National Readmission Summit Arlington VA Dec 6 th, 2013 Use of Long Term Care Services 19% 4 35% 2 20% 1 23% 1 20% 3 1. Mor
More informationtotal health and wellness Programs exclusively for our Blue Shield members For small businesses with 2 to 50 eligible employees
total health and wellness Programs exclusively for our Blue Shield members For small businesses with 2 to 50 eligible employees total health and wellness Whether you want to ease stress, lose weight, or
More informationIHI Expedition. Reducing Readmissions by Improving Care Transitions Session 2. Expedition Coordinator
Thursday, June 20, 2013 These presenters have nothing to disclose IHI Expedition Reducing Readmissions by Improving Care Transitions Session 2 Peg Bradke, RN, MA Saranya Loehrer, MD, MPH Expedition Coordinator
More informationCreating Care Pathways Committees
Presentation Creating Care Title Pathways Committees December 12, 2012 December 12, 2012 Creating Care Pathways Committees LeadingAge Indiana Integrated Care & Payment Executive Series 1 2012 Health Dimensions
More informationManaging Patients with Multiple Chronic Conditions
Best Practices Managing Patients with Multiple Chronic Conditions Dartmouth-Hitchcock Physicians Case Study Organization Profile Headquartered in Bedford, New Hampshire, Dartmouth-Hitchcock is a large
More informationTools for Better Health. Referral Toolkit. Health Care Providers
Tools for Better Health Referral Toolkit Health Care Providers A guide to working with providers to establish a referral system for evidence-based self-management programs. Table of Contents How to Use
More informationREADMISSION ROOT CAUSE ANALYSIS REPORT
USE RESTRICTED TO ABC Hospital READMISSION ROOT CAUSE ANALYSIS REPORT State: Community Name: YZ Cohort: Hospital: A ABC Hospital Reviewer: Jane Doe Abstraction Period: 1/1/2014 6/30/2014 Charts Abstracted:
More informationChronic Obstructive Pulmonary Disease
Chronic Obstructive Pulmonary Disease This booklet has been written to answer questions that many patients and family members ask about their care during their hospital stay. It will explain the experiences
More informationTop 5 Things to Know for CE:
Establishing and Maintaining Nurse Competency Lou Anne Epperson, MSN, RN Coram Specialty Infusion Services, Denver, CO Debra Moll, RN, BSN Community Surgical Infusion, Toms River, NJ Top 5 Things to Know
More informationAt EmblemHealth, we believe in helping people stay healthy, get well and live better.
At EmblemHealth, we believe in helping people stay healthy, get well and live better. Welcome to the 2017 course on Special Needs Plan Model of Care. This year s course is focused on how we can successfully
More informationTransitioning Care to Reduce Admissions and Readmissions. Sven T. Berg, MD, MPH Julie Mobayed RN, BSN, MPH
Transitioning Care to Reduce Admissions and Readmissions Sven T. Berg, MD, MPH Julie Mobayed RN, BSN, MPH Disclaimer: Potential for Error Type One Error Rejecting the null hypothesis when it is true
More informationELDER MEDICAL CARE. Elder Medical. Counseling & Support. Hospice. Care. Care
ELDER MEDICAL CARE Counseling & Support Elder Medical Care Hospice Care Mission To provide counseling, support and care to anyone with a serious illness, so they may live life to the fullest. Vision We
More informationUsing Data for Quality Improvement in a Clinical Setting. Wadia Wade Hanna MD, MPH Technical Assistance Consultant Georgia Health Policy Center
Using Data for Quality Improvement in a Clinical Setting Wadia Wade Hanna MD, MPH Technical Assistance Consultant Georgia Health Policy Center Dr. W. Hanna, PLS, November 2015 Quality An organizational
More informationInnovation. Successful Outpatient Management of Kidney Stone Disease. Provider HealthEast Care System
Successful Outpatient Management of Kidney Stone Disease HealthEast Care System Many patients with kidney stones return to the ED multiple times due to recurrent symptoms. Patients then tend to receive
More informationHospital Readmissions
Hospital Readmissions The Long-Term Care Provider s Ultimate Survival Guide to Incorporating INTERACT TM Into Health Information Technology (HIT) In this survival guide, we ll give you the tips you need
More informationCommunity Paramedicine: Lessons Learned from South Carolina
Community Paramedicine: Lessons Learned from South Carolina Dr. Chris Oxendine, CP Medical Director Abbeville Area Medical Center Will Blackwell Abbeville County EMS Sarah M. Craig, MHA South Carolina
More informationThe STAAR Initiative
The STAAR Initiative Getting Started Kit for the STAAR Collaborative September 2010 Institute for Healthcare Improvement, 2010 Page 1 Table of Contents STAAR Collaborative Charter... 3 Statement of Need...
More informationSkilled Nursing Facility (SNF) Shared Best Practices to Reduce Potentially Preventable Readmissions (PPRs)
Skilled Nursing Facility (SNF) Shared Best Practices to Reduce Potentially Preventable Readmissions (PPRs) Referral Review referrals to determine if care needs can be met in your facility by: Triaging
More informationMEDICATION THERAPY MANAGEMENT. MemberChoice FORMULARY MANAGEMENT MEDICATION THERAPY MANAGEMENT (MTM) SPECIALTY DRUG MANAGEMENT
MemberChoice FORMULARY MANAGEMENT MEDICATION THERAPY MANAGEMENT (MTM) SPECIALTY DRUG MANAGEMENT MEDICATION THERAPY MANAGEMENT Medication Therapy Management 1 $ 290 Billion Wasted in avoidable costs due
More informationUse of Health Information Technology to Reduce Health Risk
Use of Health Information Technology to Reduce Health Risk Sandra M. Foote Senior Advisor, Chronic Care Improvement Centers for Medicare & Medicaid Services September 9, 2005 The MHS Challenge Develop
More informationA Care Transitions Project
Hospital to Home: A Care Transitions Project Ann Roemen, MBA, CMPE Readmissions 1 in 5 elderly patients Resultsin23million 2.3 re-hospitalizations Annual cost to Medicare - $17 billion + Jencks SF,Williams
More informationTHE 2017 QUALIS HEALTH AWARDS OF EXCELLENCE IN HEALTHCARE QUALITY IN WASHINGTON
THE 2017 QUALIS HEALTH AWARDS OF EXCELLENCE IN HEALTHCARE QUALITY IN WASHINGTON Since 2002, Qualis Health has presented the annual Awards of Excellence in Healthcare Quality to outstanding organizations
More informationPutting the Patient at the Center of Care
CMMI Innovation Advisor Paula Suter, Sutter Care at Home: Putting the Patient at the Center of Care Paula Suter, of Sutter Care at Home, joins the Alliance for a discussion of her work with the Center
More informationCommunity Health Excellence (CHE) Grant Program Application Guide
Community Health Excellence (CHE) Grant Program 2018 2019 Application Guide CHE Mission and Goals The PacificSource Community Health Excellence (CHE) initiative was created to align with and support the
More informationDrivers of HCAHPS Performance from the Front Lines of Healthcare
Drivers of HCAHPS Performance from the Front Lines of Healthcare White Paper by Baptist Leadership Group 2011 Organizations that are successful with the HCAHPS survey are highly focused on engaging their
More informationHeart Failure Education Consider Health Literacy
Heart Failure Education Consider Health Literacy Sandy Hall RN BSN Heart Failure Case Manager Mercy Medical Center Des Moines, IA August 2012 What does this mean to you? Cardiac diet 1 Is it this? Low
More informationCare Transitions: Don t Lose Your Patients
Care Transitions: Don t Lose Your Patients Sabrina Edgington, MSSW Program and Policy Specialist National Health Care for the Homeless Council March 14, 2013 CARE TRANSITIONS Definition The movement of
More informationIntroduction. Singapore. Singapore and its Quality and Patient Safety Position 11/9/2012. National Healthcare Group, SIN
Introduction Singapore and its Quality and Patient Safety Position Singapore 1 Singapore 2004: Top 5 Key Risk Factors High Body Mass (11.1%; 45,000) Physical Inactivity (3.8%; 15,000) Cigarette Smoking
More informationInaugural Barbara Starfield Memorial Lecture
Inaugural Barbara Starfield Memorial Lecture Wonca World Conference Prague, June 29, 2013 Copyright 2013 Johns Hopkins University,. Improving Coordination between Primary and Secondary Health Care through
More informationAdopting Accountable Care An Implementation Guide for Physician Practices
Adopting Accountable Care An Implementation Guide for Physician Practices EXECUTIVE SUMMARY November 2014 A resource developed by the ACO Learning Network www.acolearningnetwork.org Executive Summary Our
More informationImproving the Quality of Care Coordination Across Settings
Improving the Quality of Care Coordination Across Settings Eric A. Coleman, MD, MPH Associate Professor Divisions of Geriatric Medicine and Health Care Policy and Research University of Colorado Health
More informationMaternity Management. The best part? These are available to you at no additional cost. Intro
Telligen provides the following services for Connecticut Carpenters members to help you better manage your health and enjoy a good quality of life. The programs include both Maternity Management and Condition
More informationJournal of the Association of American Medical Colleges ACCEPTED
Journal of the Association of American Medical Colleges Uncomposed, edited manuscript published online ahead of print. This published ahead-of-print manuscript is not the final version of this article,
More informationDischarge Information
Discharge Information Yes, patients were given information about what to do during their recovery Vikki Choate, MSN, RN, CCM, RN-BC, CPHQ Nashville, TN May 14-15, 2013 Learning Objectives At the end of
More informationEvidence Summary for the Care Transitions Program
Social Programs That Work Review Evidence Summary for the Care Transitions Program HIGHLIGHTS: PROGRAM: The Care Transitions Program is a low-cost hospital discharge planning and home follow-up program
More informationReducing Hospital Admissions Through the Use of IT. Steven Milligan MD Medical Director of ACO Management Colorado Health Neighborhoods
Reducing Hospital Admissions Through the Use of IT Steven Milligan MD Medical Director of ACO Management Colorado Health Neighborhoods Conflict of Interest Steven Milligan, MD Has no real or apparent conflicts
More informationManaging Patients with Multiple Chronic Conditions
Best Practices Managing Patients with Multiple Chronic Conditions Fletcher Allen Health Care Case Study Organization Profile Located in Burlington, Fletcher Allen Health Care (FAHC) is Vermont s university
More informationImproving Hospital Performance Through Clinical Integration
white paper Improving Hospital Performance Through Clinical Integration Rohit Uppal, MD President of Acute Hospital Medicine, TeamHealth In the typical hospital, most clinical service lines operate as
More informationAn Initiative to Improve Patient Discharge Satisfaction
An Initiative to Improve Patient Discharge Satisfaction Speaker Disclosure Statement Sally Strong, RN, APN-CNS, CNRN, CRRN Clinical Nurse Specialist Marianjoy Rehabilitation Hospital Adjunct Faculty Elmhurst
More informationModule 7. Tips for Family and Friends
Module 7 Tips for Family and Friends The Heart Failure Society of America (HFSA) is a non-profit organization of health care professionals and researchers who are dedicated to enhancing quality and duration
More informationPolicy & Providers. for Managing Chronic Care Patients. Mary Alexander Strategic Alliances Director - Home Instead, Inc. Kelly Funk.
Policy & Providers Lessons From The Health Care Arena for Managing Chronic Care Patients Producer: Bob Bua President - CareScout Panel: Peter Sosnow VP Corporate Development - Humana / SeniorBridge Mary
More informationPerformance Measurement of a Pharmacist-Directed Anticoagulation Management Service
Hospital Pharmacy Volume 36, Number 11, pp 1164 1169 2001 Facts and Comparisons PEER-REVIEWED ARTICLE Performance Measurement of a Pharmacist-Directed Anticoagulation Management Service Jon C. Schommer,
More information[Evelyn will get back to us this evening with her changes.]
Page 1 of 10 Introduction Hello, my name is Mary Burke, RN. I have more than 20 years of experience as a nurse; primarily in outpatient and clinic settings. I m now at the University of Iowa Hospitals
More informationTransitions of Care: From Hospital to Home
Transitions of Care: From Hospital to Home Danielle Hansen, DO, MS (Med Ed) Associate Director, LECOM VP Acute Care Services & Quality/Performance Improvement, Millcreek Community Hospital Objectives Discuss
More informationPresenter Disclosure
Improving Transitions from the Hospital to Community Settings IHI National Forum Learning Lab Sunday, December 9, 2012 Session L20 Presenter Disclosure Leora Horwitz, MD Assistant Professor of medicine
More informationVNAA BLUEPRINT FOR EXCELLENCE BEST PRACTICES TO REDUCE HOSPITAL ADMISSIONS FROM HOME CARE. Training Slides
VNAA BLUEPRINT FOR EXCELLENCE BEST PRACTICES TO REDUCE HOSPITAL ADMISSIONS FROM HOME CARE Training Slides 061015 Why Take Action to Prevent Readmissions? Better patient care and patient experience Home
More informationIncreasing Access to Medicines to Enhance Self Care
Increasing Access to Medicines to Enhance Self Care Position Paper October 2009 Australian Self Medication Industry Inc Executive summary The Australian healthcare system is currently at a crossroads,
More informationMedication Reconciliation: Looking Forward
Medication Reconciliation: Looking Forward Bruce Lambert, Ph.D. Associate Professor Department of Pharmacy Administration University of Illinois at Chicago 833 S. Wood St. (MC 871) Chicago, IL 60612-7231
More informationSTROKE REHAB PROGRAM
STROKE REHAB PROGRAM Allied Rehab Hospital is part of Allied Services Integrated Health System, the premier post-acute health-care system in Northeast Pennsylvania, and is the region s leading provider
More informationACO Practice Transformation Program
ACO Overview ACO Practice Transformation Program PROGRAM OVERVIEW As healthcare rapidly transforms to new value-based payment systems, your level of success will dramatically improve by participation in
More information